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} SAN OAQUIN Environmental Health Department <br /> COUNTY <br /> `�rFo ?P Greotness gro�vs here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: p Owner Name: r Date: <br /> l , <br /> ax <br /> CFO Physical Address: CFO City: CFO Zip: <br /> a UI �4G ��iC�C-lv�d (zocr� (La R53� <br /> Website(If applicable): Tele hone: <br /> ( CRS 993 -057q <br /> 1. Categories: <br /> < "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT4Fod <br /> Only <br /> foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottagration. <br /> These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br /> cause of food-borne illness. <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list of <br /> ingredients (attach separate page if needed). <br /> Food List,_ <br /> UpC0.K�5 C No <br /> Pops <br /> C�hoct�lc� cc_)s(P_JeA non puis"c kie <br /> C s ec�Jm Ac A_�' )(4 s <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label is required if only one product is <br /> made). <br /> 5. Water Source: <br /> Please check what type of water source is being usedthe CFO: <br /> ❑ City Water rivate Well* <br /> "If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> 6. Food Processor Course: <br /> Attach food handler certification for owner and each individual that were not submitted with initial application <br /> (including family members and/or employees). <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />